Chapter 18

Tachycardia

Above 160 bpm

Vitamin K nursing implications

Administer within 1 to 2 hours after birth Give as an IM injection at a 90° angle into the outer middle third of the vastus lateralis muscle Use a 25 gauge, 5/8 of an inch needle for injection The dose is .5 to 1 mg Hold the leg firmly and inject medication slowly Adhere to standard precautions Assess for bleeding at injection site after administration

Post term or post dates

After week 42 gestation

What is included in an initial newborn assessment?

Apgar scoring, length and weight, vital signs, gestational age assessment, physical maturity, neuromuscular maturity

General newborn care

Bathing and hygiene, elimination and diaper area care, cord care, circumcision care, environmental safety measures, and prevention of infection, sleep promotion, bonding, teaching all of this to parents

Erythromycin ointment 0.5% or tetracycline ophthalmic ointment 1% - Nursing implications

Be alert for chemical Conjunctivitis for 1 to 2 days Gloves, and open eyes by placing a thumb and finger above and below the eye Gently squeeze the tube or ampule to apply medication into the conjunctival sac from the inner canthus to the outer canthus of each eye Do not touch the tip to the eye Close the eye to make sure the medication permeates Wipe off excess ointment after one minute

Mongolian spots

Benign blue or purple splotches that appear solitary on the lower back and buttocks, maybe multiple over legs and shoulders Occur in AA, Asian, Hispanic, and Indian newborns Concentration of pigmented cells Disappear within first 4 yrs of life

Cephalhematoma

Bleeding between the periosteum and skull from pressure during birth; does not cross suture lines. Usually from prolonged labor or the use of obstetric interventions such as low forceps or vacuum extraction; swelling with no overlying skin discoloration; aspiration is not required because it increases the risk of infection; usually appears on the second or third day after birth and disappears within weeks; large ones can lead to increased Bilirubin levels and subsequent jaundice.

Skin: condition and color

Check turgor to detect dehydration by pinching a small area of skin over the chest or abdomen and note how quickly it returns to its original position May appear cracked or peeling skin may appear blotchy and modeled acrocyanosis is normal observe head for symmetry in rounders in the neck for congenital malformations Skin should be warm to the touch and intact Lanugo might be found on the shoulders, side of face, and upper back

Bonding

Comfort measures, swaddling, nurturing behaviors

Nursing Management: Early Newborn Period: Breast-Feeding

Composition: changes over time from colostrum -> transitional -> mature. Colostrum is a thick, yellowish substance secreted during the first few days after birth. High in protein, minerals, and fat-soluble vitamins. It is rich in immunoglobulins A, which help protect the newborn's GI tract against infections. It is a natural laxative that helps rid the intestinal tract of meconium quickly. Transitional milk contains all the nutrients in colostrum, but its thinner and less yellow. Is replaced by true or mature milk around day 10 after birth. Mature milk appears bluish and is not as thick as colostrum. It provides 20 cal/oz and contains protein (whey), high fats, high cholesterol, carbs (lactose), water (main ingredient), minerals, vitamins, and enzymes (lipase and amylase). Assistance: dry cloth, place skin to skin on mom, warmed blanket Keys to successful bf: within first hr, chest/abdomen of mom, 8-12 times/day, unrestricted periods, no supplement unless medically indicated, lactation consultant, avoid artificial nipples and pacis unless painful procedure needed, increase fluid intake, feed from both breasts, indicators of aqequate intake, baby stays with mom as much as possible, nurse and lactation consultant PRN Positioning: pillows or folded blanket under mom's head, or rolling her to one side and tucking the newborn next to her. Four most common: football, cradle, cross-cradle, side-lying. Make a C- or V- shape with fingers to help with latch. Education: non-judgmental; demonstrate techniques and offer encouragment/praise Storage and Expression: express manually or by a pump; use sealed and chilled milk within 24 hr; discard any that has been in fridge for 24 hrs or longer; use any frozen expressed milk within 3 mo; discard any unused milk (do not refreeze it); store milk in quantities for each feeding (2 to 4 oz); thaw milk in warm water before using. Concerns: Sore, cracked nipples- find cause, change positioning/fix latch, use warm water to clean nipples to prevent dryness, express some milk before to stimulate let-down, cold compresses, massage breast milk onto nipples after feeding, wear correct bra, anti-inflammatories, air-dry, etc. Engorgement- may come in as the milk comes in around day 3 or 4; warm, manual expression before feeding, supportive nursing bra, variety of positions, increased frequency, warm compresses before, etc. Mastitis- usually in one breast; rest, warm compresses, antibiotics, breast support, continued breastfeeding

caput succedaneum

Describes localized edema on the scalp that occurs from the pressure of the birth process. It is commonly observed after prolonged labor. It appears as a poorly demarcated soft tissue swelling that crosses suture lines. Pitting edema and overlying petechiae and ecchymoses are noted. The swelling will gradually dissipate in about three days without any treatment. Newborns who were delivered via vacuum extraction usually have a Caput in the area where the cup with used.

Harlequin sign

Dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit Midline dermacation (pale on nondependent side and red on dependent side) Immature auto regulation of blood flow and is commonly seen in low birth weight newborns when there is a positional change Transient, lasting as long as 20 min

Initial newborn assessment

Done to look for any problems Transition to extrauterine life occurs within the first several hours after birth The first assessment is done in the birthing area to see if the newborn is stable enough to stay with parents or if any resuscitation/immediate interventions are needed Second assessment is done within the first 2 to 4 hours when the newborn is admitted to the nursery or the labor and delivery room (wherever the parents are) Purpose of the assessments: determine newborns overall health status, to provide info to the parents, iand to ID physical abnormalities

Nursing Management: Early Newborn Period: Discharge Preparation

First follow-up visit for newborn within 2-4 days after discharge (more lab work), then 2-4 weeks, 2, 4, 6 mo for checkups and vaccines, 9 mo for checkup, 12 mo for checkup and TB testing, 15 and 18 mo for checkups and vaccines, and 2 yrs for a checkup Call PCP about s/s of newborn illness - temp of 101F or higher - vomiting - poor feeding - two or more green watery stools - infrequent wet diapers and changes in bowel pattern - excessive tiredness - extreme crying/fussy - abdominal distention - difficult or labored breathing Shots: educate about typical shot schedule; first shot (Hep B)- hospital soon after birth or by 2 mo if mom is negative, positive- vaccine and IG within 12 hrs after birth; risks, benefits, adverse effects, right to refuse

Nursing Management: Early Newborn Period: Nursing Interventions

General newborn care Bathing and hygiene Elimination and diaper area care

macrocephaly

Head circumference more than 90% of normal, typically related to hydrocephalus. It is often familial with autosomal dominant inheritance and can be either an isolated anomaly or manifestation of other anomalies, including hydrocephalus and skeletal disorders.

Molding

Head circumference more than two standard deviation's below average or less than 10% of normal parameters for gestational age, caused by failu of brain development. It can be familiar, with autosomal dominant or recessive inheritance, and it may be associated with infections.

microcephaly

Head circumference more than two standard deviation's below average or less than 10% of normal parameters for gestational age, caused by failure of brain development. It can be familial, with autosomal dominant or recessive inheritance, and it may be associated with infections, rubella, toxoplasmosis, trisomy 13, 18, or 21 and fetal alcohol syndrome.

What is the most important sign on the Apgar scale?

Heart rate

VS normals

Heart rate and respiratory rate are assessed STAT after birth with Apgar scoring Heart rate: listen for one full minute at the apical pulse (normal: 110-160) Respiratory rate: place stethoscope on right chest; listen for one whole min Heart rate and respiratory rate are assessed every 30 minutes until stable for two hours after birth, then checked every eight hours Axillary temperature is usually done at the second assessment; sometimes immediately after Apgar score to detect hypothermia Blood pressure is not routinely assist unless there's a clinical indication or low Apgar scores

LATCH Method for Assessing Breast-Feeding Sessions

L: How well infant latches onto the breast A: Amount of audible swallowing T: Nipple type C: Level of comfort H: Amount of help mother needs

Length and Weight

Length is measured from the newborns head to the newborns heel with the newborn unclothed: legs should be fully extended The expected length of a full term newborn is usually 44 to 55 cm or 17 to 22 inches Molding can affect a measurement Length is measured by disposable tape measure or built-in measurement board located on the side of some scales Weight- The typical newborn weighs 2500 to 4000 g or 5 lbs. 8 oz. to 8 lbs. 14 oz. Birthweights less than 10% or more than 90% on a growth chart or outside the normal range and need further investigations Newborns can be classified by their birthweight regardless of their gestational age as follows: low birth weight: above 2500 g or 5.5 pounds, very low birth weight: above 1500 g or 3.5 pounds, extremely low birth weight: above 1000 g or 2.5 pounds Newborns can lose up to 10% of their initial birthweight by 3 to 4 days of age secondary to loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life. Wait measured by digital scale & tracked on flowsheet

Bradycardia

Less than 100 bpm

bradypnea

Less than 25 breaths per minute

Mouth

Lips- intact with symmetric movement and positioned midline; no lesions, pink and moist; sucking reflex; variations: cleft upper lip, thin upper lip (FAS) Swallowing, sucking, gag reflexes in tact Positions of structures are correct Mucous membranes should be pink and moist, with minimal saliva present Normal variations: Epstein's pearls, erupted natal teeth, thrush

Nursing interventions: immediate newborn period

Maintain airway patency: suction mouth, then nose with bulb syringe (prevent aspiration of fluids into the lungs by unexpected gas); not required to use bulb, can also use a towel Ensuring proper identification: make sure nurse or other health healthcare professional have ID on; parents get matching ID bands with infant; infant has two bands, wrist and ankle; name, gender, time, date, ID number; electronic devices sound off if babies removed from area; baby's foot prints on form with mom's fingerprints, name, date, and time of birth; Taking a newborns picture within two hours after birth also helps prevent mixups and abduction Vit. K: Fat soluble vitamin given to promote clotting through increasing prothrombin synthesis from the liver; not produced in intestine into micro organisms have been introduced (because newborn bowel is sterile) through first feeding; usually takes one week for newborn have enough vitamin K to provide adequate clotting Eye prophylaxis: all newborns in the US must receive this within the first one or two hours after birth to prevent ophthalmic neonatorum, which can cause newborn blindness; 5% erythromycin ointment Maintaining thermoregulation: Cap, blankets, skin to skin, dry thoroughly, etc.

genitalia

Male- smooth glans, meats centered at tip of penis, foreskin can cover glans if not circumcised, observe for hypospadias or epispadias; inspect scrotum for size, symmetry, color, rugae, location of testes; observe for edema, discoloration, or bulging; palpate for testes Female- inspect external genitalia; urethral meatus below clitoris and is midline; engorgement of the labia minors and majors, large clitoris, thick hymen (estrogen and progesterone); pseudomenstrutation common in first few weeks Both- anus for position and patency (passage of meconium; rectal thermometer or DRE if not)

Large fontanelles

More than 6 cm in the anterior diameter bone to bone or more than a 1 cm diameter in the posterior fontanelle; possibly associated with malnutrition,, hydrocephaly, congenital hypothyroidism, trisomy 13, 18, and 21, and various bone disorders such as osteogenesis imperfecta.

Tachypnea

More than 60 breaths per minute

Neck

Movement and ability to support the head Should move freely in all directions and should be capable of holding the head in a midline position Should be able to hold up head briefly without support Clavicles should be straight and intact Monitor for fx clavicles (edema, crepitus, decreased or absent movement, pain or tenderness on affected side) - immobilize

Initial newborn assessment: signs indicating a problem

Nasal flaring, chest retractions, grunting on exhalation, labored breathing, generalized cyanosis, flaccid body posture, abnormal breath sounds, abnormal respiratory rates, abnormal heart rates, abnormal newborn size

Newborn nutritional needs: calories

Needs lots of energy, protein, vitamin, minerals to fuel rapid growth and development Birth weight doubles in the first 4-6 mo of life and tripled within first year Calories- 110-120 cal/kg body weight

Supporting the choice of feeding method

Nurse should advocate for breastfeeding Regardless of which method is chosen, the nurse needs to respect and support the couple's decision Before the newborn can be fed, determine his or her ability to suck and swallow, bulb syringe, auscultate bowel sounds, check for abdominal distention, inspect anus for patency Most on demand feeding schedules and are allowed to feed when they awaken When at home, mom should feed q2-4 hr during the day and only when newborn awakes during the night for the first few days Should be fed on demand when they display signs of hunger Most breastfed babies need to be fed every 2-3 hours, nursing from 10-20 minutes on each breast Length of feedings is up to mom and baby Formula fed babies usually feed q3-4 hrs, finishing a bottle in 30 min or less Daily formula intake for an infant should be 1.5 to 2 oz/lb of body weight, but growth is a better measure of health than the amount of formula consumed How to know if baby is receiving sufficient milk? Wets diaper 6-10 times per day, produces several stools per day, sleeps well, gains weight regularly, seems satisfied Newborns swallow air during feedings, which causes discomfort and fussiness. Can prevent this by burping them frequently throughout the feeding Feeding time is also for bonding/closeness/sharing

Acrocyanosis

Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness; it may be seen in newborns during the first few weeks of life in response to exposure to cold; normal and intermittent; any change in color needs to be investigated.

Eyes

Position, color, size, movement May be marked edema of the eyelids and subconjunctival hemorrhage due to pressure during birth Eyes should be clear and symmetrically placed Blink reflex; pupillary reflex Gaze: track things to midline Many have transient strabismus and searching nystagmus (normal for 3-6 mo) Red reflex (retina) should be seen bilaterally Chemical conjuctivitis is common after eye prophylaxis within 24 hr after admin; lid edema, sterile discharge bilaterally; resolves within 48 hrs without tx

Newborn physical exam

Prenatal history Newborn physical exam - anthropometric measurements: length, weight, head circumference, chest circumference - vital signs - skin: condition and color; common skin variations Head: size, fontanelles; variations in head size and appearance; abnormalities in head or fontanelle size Face: nose, mouth, eyes, ears Neck, chest Abdomen Genitalia Extremities and back Neuro status(alertness, posture, muscle tone, reflexes)

Preterm or premature

Prior to 37 weeks gestation

Erythromycin ophthalmic ointment 0.5% or tetracycline ophthalmic ointment 1% - action/indication

Provides bactericidal bacteriostatic actions to prevent Neisseria gonorrhea and chlamydia trachomatis conjunctivitis Prevents ophthalmic neonatorum

phytonadione (Vitamin K, Aqua-Mephyton, Konakion, Mephyton)- Action/Indication

Provides the newborn with vitamin K (necessary for production of adequate clotting factors two, seven, nine, and 10 by the liver) during the first week of birth until the newborn can manufacture it Prevents vitamin K deficiency bleeding of the newborn

Abdomen

Shape and movement Protuberant but not distended Auscultation Bowel sounds in all quadrants Palpate (bowels, liver, kidneys, masses) Inspect umb cord area for correct number of umbilical vessels, bleeding, infection, inflammation, redness, swelling, purulent drainage, granuloma, placement

Head

Should appear symmetric and round Most congenital malformations are found on the head and neck View all angles The newborn has two fontanelles at the juncture of the cranial bones Anterior fontanelle diamond shaped and closest by 18 to 24 months Typically it measures 4 to 6 cm at the largest diameter The posterior fontanelle is triangular, smaller than in tear your body now (usually fingertip size or .5 to 1 cm), and should be closed by 6 to 12 weeks Palpate fontanelles for softness, flatness and openness, then palpate the skull The skull should feel somewhat smooth and fused, except at the areas of the fontanelles, over molding areas, and sutures. Variations and head size and appearance: molding, Caput succedaneum, cephalohematoma Common abnormalities in head or fontanelle size: microcephaly, macrocephaly,large fontanelles, small or closed fontanels

Face

Should be full and symmetrical when the baby is resting and crying The newborn may have bruising and reddened areas over both cheeks and parietal bones secondary to the pressure of the forceps blades. Resolves without tx. Facial nerve paralysis can also occur from trauma due to forceps. Apparent on 1st or 2nd day of life. Typically, this is shown through asymmetry of the face with an inability to close the eye and move lips on that particular side; also difficulty sealing around nipple/formula goes everywhere. Most resolves within a few days, although can take weeks to months. Determine cause!

Ears

Size, shape, skin condition, placement, amount of cartilage, and patency of the auditory canal Soft, pliable, recoil quickly and easily when folded and released Ears should be aligned with outer canthi of eyes (abnorm: trisomy 13 or 18, renal abnorm) Sinuses or preauricular skin tags-> problems with kidneys No ear exams via otoscopy (amniotic fluid and vernix all in there) Hearing loss screening (turns towards noises and startles at loud ones)

Chest

Size, shape, symmetry Round, symmetric, and 2-3 cm smaller than head circumference Xiphoid process may or may not be seen Nipples may be engorged with white discharge (estrogen) Extra small nipples may be present (harmless) Barrel shaped chest with normal anterioposterior and lateral diameters Auscultation lungs bilaterally for equal breath sounds Fine crackles heard upon inspiration are normal (amniotic fluid clearance) Heart sounds when baby is quiet or sleeping (Maximal point of impulse- lateral to midclavicular line at 4th inter coastal space) Murmurs usually normal findings (foremen ovale closing)

Nose

Size, symmetry, lesions, position Small and narrow; midline, patent nares, intact septum Equal nostril size Preferential nose breather; can sneeze to clear nose PRN Must suction

Small or closed fontanelles

Smaller than normal anterior and posterior diameter's or fontanelles that are closed at birth. Craniosynostosis and abnormal brain development are associated with a small fontanelle or early fontanelle closure associated with microcephaly.

Physiological changes

Stomach capacity limited: peristalsis is rapid, emptying time is short (2-3 hrs); small, frequent feedings needed, progressing with maturity Immune system immature (high risk for food allergies during 4-6 mo Pancreatic enzymes and bile digest fat and starch in limited supply until 3-6 mo Kidneys immature and unable to concentrate urine until 4-6 wk; need more water At about 4-6 mo, inborn reflexes disappear, head control develops, and infant can be sit up when feeding

Vital Signs (VS)

Taken upon nursery admission, then every 30 minutes until stable for two hours, then every 4 to 8 hours; blood pressure not routinely checked; murmurs detected do not necessarily indicate congenital heart disease, but should be tracked

What can influence the Apgar score?

The presence of infection, newborn maturity, mothers age, congenital anomalies, physiologic immaturity, maternal sedation via medications, labor-management, and neuromuscular disorders.

Vernix caseosa

Thick white substance that protects the skin of fetus Found within first 2-3 days after birth in body creases and hair Absorbed into skin

Sleep promotiom

Up to 15 hrs per day 2-4 hrs at a time Not through the night Back Prevent suffocation No co-sleeping Crib Room share Firm mattress

Elimination and diaper care

Urine- light amber in color; 6-12 diapers a day Stools- meconium within 48 hrs Top edge of diaper folded down; point penis down Observe area for irritation or rash

Gestational age assessment

Uses a Ballard scale It determines the newborns gestational age between 20 and 44 weeks The scores is assigned to the various parameters, and the total score corresponds to maturity Points are given for each assessment perimeter, with a low score of negative one point or -2 points for Xtreme immaturity to four or five points for postmaturity; The scores for each section are added to correspond to a specific gestational age in weeks Physical maturity section is done during the first two hours after birth Neuromuscular maturity section typically is completed within 24 hours after birth

Appropriate for gestational age (AGA)

Weight between 10th and 90th percentile's

small for gestational age (SGA)

Weight less than the 10th percentile on standard growth charts (usually below 5.5 pounds)

Large for gestational age (LGA)

Weight more than the 90th percentile on standard growth charts (usually above 9 pounds)

Anthropometric measurements: length, weight, head circumference, Chest circumference

Weight: newborns are weighed immediately after birth and daily; newborns usually lose up to 6% of their birthweight within the first few days of life, but regain it in approximately 10 Days; place a warmed protective cloth or paper as a barrier on the scale to prevent heat loss by conduction; keep a hand above the newborn for safety Head circumference: the average newborn head circumference is 32 to 38 cm (13 to 15 inches). Measure the circumference of the heads widest diameter (the occipitofrontal circumference). Wrap a flexible or paper measuring tape snugly around newborns head and record the measurement. The circumference should be approximately 1/4 of the newborn length or about half infants body length +10 cm. Chest circumference: the average chest circumference is 30 to 36 cm or 12 to 14 inches. It is generally equal to or about 2 to 3 cm less than head circumference. Please stay flexible or paper tape measure around the enclave newborns chest just below the nipple line without pulling it tig yes circumference: the average chest circumference is 30 to 36 cm or 12 to 14 inches. It is generally equal to or about 2 to 3 cm less than head circumference. Place a flexible or paper tape measure around the unclothed newborns chest just below the nipple line without pulling it taut.

postmature

after week 42 gestation/placental aging

Prenatal history

complications, group B strep, HIV, Hep B

Stork bites

"Salmon patches" Superficial vascular areas found on nape of neck, eyelids, between eyes and upper lip Concentration of newborn blood vessels May fade and disappear completely within 1st year

Nursing interventions to help maintain body temperature include:

-Dry the newborn immediately after birth to prevent heat loss through evaporation. - Wrap the baby in warmed blankets to reduce heat loss via convection. - Use a warmed cover on the scale to weigh the unclothed newborn. - Warm stethoscopes and hands before examining the baby or providing care. - Avoid placing newborns in drafts or near air vents to prevent heat loss through convection. - Delay the initial bath until the baby's temperature has stabilized to prevent heat loss through evaporation. - Avoid placing cribs near cold outer walls to prevent heat loss through radiation. - Put a cap on the newborn's head after it is thoroughly dried after birth. - Place the newborn under a temperature-controlled radiant warmer Temp taken every 30 minutes for the first two hours or until the temperature has stabilized, and then every eight hours until discharge or follow hospital protocols Commonly, an automatic sensor is attached to the newborn on RUQ to record body temperature; it sounds off if the temperature is out of range

Fluid requirements

100-150 mL/kg daily Can be meet through breast/bottle feeding Feedings also help with adequate carbs, fats, proteins, vitamins Bottle fed infants need iron supplements Breast fed infant needs iron at 6 mo Both need daily vitamin D supplement Fluoride supplements not receiving fluoridated water after 6 mo Iodine supplements for moms

Term

38 to 42 weeks gestation

APGAR scoring

A = appearance (color) P= pulse (HR) G= grimace (reflex irritability) A= activity (muscle tone) R= respiratory (respiratory effort) Looks like the physical condition of the newborn Done it one minute and five minutes after birth; another done at 10 minutes if the five minute score is less than seven One minute score provides information about the newborns adaptation to extrauterine life Five minute score provides info about the overall status of the CNS Each parameter is assigned a score from 0 to 2 Normal score is 8 to 10; above eight requires no intervention except maintaining thermoregulation and respiratory effort Moderate difficulty is score of 4-7 Severe distress is the score of 0 to 3 When the newborn experiences characteristics of physiological depression, Apgar scores decline in a predictable manner: color, respiratory, tone, reflexes, heart rate

Nursing Management: Early Newborn Period: Bottle-Feeding

•Types of formula: usually cow's milk if full-term, but may switch to a lactose free formula if needed (up to PCP); need iron-fortified formula until 1 yr; 3 forms- powder, concentrate, and easy to feed or ready to use; boil water for 1-2 min then get to room temp before mixing in •Assistance: cuddle, position head in comfy spot, communicate with baby, both position of baby and bottle needs to be correct •Positioning: comfort needed (chair, pillow, support head, hold close, head raised slightly •Education: never prop bottle, never freeze formula or warm it in a microwave, bottle like a pencil, hold so nipple remains filled with milk, burp infant every few ounces, bulb syringe nearby, no putting baby to bed with bottle, feed q3-4 hr, prep enough for next 24 hr, store unmixed, open liquid formula in the fridge for up to 48 hrs, through away left over formula in bottle, too little water: hypernatremia/dehdration, too much water: FTT, poor nutrition, fluoride overdose, lack of weight gain •Weaning and introduction of solid foods: depends on mother and baby, usually occurs b/t 6 mo - 1 yr; foods can be introduced when infant doubles their birth weight and weighs at least 13 lb (cereal, fruit, veggies, meat, eggs)